the willingness of the Government to show that the programs which they design promote the principle of equity among the citizens (Official Gazette of the Republic of Macedonia 2008b). the PAP screening was offered free of charge to the insured women as well, as offering a service “free of charge” was seen as the most efficient strategy for its promotion (I_15_SG_KU_g); the activities envisaged to increase coverage were not appropriate for the uninsured women, as a particularly hard to reach target group, and this was not foreseen as a possible obstacle to mobilize 12.000 uninsured women; the goal to include 20% of the uninsured women was set too high, so the available resources would not be used up if the target group was limited to the uninsured women only.
Another controversial aspect of the design of the vertical program, was the switch of the responsible institutions for the delivery of the screening services in 2007. While in 2005 and 2006 the primary gynecologists were completely involved in the Program, in the years to follow higher level health care facilities took over the responsibilities. As this decision has both financial and ethical implications, the research tried to explore the reasons behind this decision. One of the possible explanations for not choosing primary gynecology facilities for performing the free-of-charge PAP examinations is their privatization, which took place in 2007, in the same time period when the screening Program was launched. The general financial environment in which the primary gynecologists, especially the concessionaires worked in the beginning of their establishment as private entities was still fragile. As the new HIF contractors, their obligation was to provide health services for the insured women, and they had a right to decline working with the women not covered with the health insurance, in case no common ground was found on the terms these services would be performed. The secondary and tertiary level institutions in contrary were in majority public and as such they were much easier partner for negotiation of the terms and conditions under which to perform the free-of-charge screening. This is the most probable reason for including them in this public health initiative by the Ministry of Health, as the main designer of the Program.
The choice of the biggest cytology laboratory, which is based at a tertiary level institution, as a place where all samples of the campaign would be examined, by some was regarded as an opportunity for achieving higher quality of the cytology examinations, as this laboratory is regarded as a reference one (I_09_TG_SK). By others, on contrary, this decision was seen as a possible threat to the quality assurance, as the resources in this laboratory were not adequate for a “campaign-
DISCUSSION
However, the choice of secondary and tertiary gynecologists as the responsible for taking PAP smear, would mean overburdening their capacities at one side, and depriving the patient of the right to be counseled at the other, as the higher level gynecologists do not recognize the counseling of the patient as their responsibility (I_03_SG_PP_j; I_09_TG_SK_h).
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